Family Practice Advance Access originally published online on April 1, 2005
Family Practice 2005 22(3):269-274; doi:10.1093/fampra/cmi018
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A qualitative study of choosing and using an NHS Walk-in Centre
a Department of Health Sciences, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP and b National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Old Road, Headington, Oxford OX3 7LF, UK
Correspondence to Mary Dixon-Woods; Email: md11{at}leicester.ac.uk
Received 28 May 2004; Accepted 5 January 2005.
Jackson CJ, Dixon-Woods M, Hsu R and Kurinczuk JJ. A qualitative study of choosing and using an NHS Walk-in Centre. Family Practice 2005; 22: 269–274.
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Abstract |
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Background. NHS Walk-in Centres have been introduced to improve access to healthcare in the UK. Little is understood about why people choose Walk-in Centres from among the range of options available to them.
Objectives. To explore users' accounts of choosing and using an NHS Walk-in Centre.
Methods. Semi-structured interviews with 23 users who had recently attended an NHS Walk-in Centre were conducted. Analysis was based on the constant comparative method.
Results. Participants' accounts revealed two types of service use: those who knew what was wrong with them and had a clear idea of what treatment was required, and those seeking professional advice. Users reported "solidarity" with the NHS and other NHS users, and were highly sensitive to the demands on both Accident and Emergency and GP services in their choice of services. The Walk-in Centre appeared to function as a means of overcoming the barriers to healthcare associated with other healthcare services, although there was some lack of clarity about the purpose of the Walk-in Centre.
Conclusions. Users' accounts suggest that NHS Walk-in Centres improve access to healthcare by opening up an alternative means of seeking a professional opinion or treatment. It is especially important in allowing people to use the NHS without feeling that they are increasing the burden on general practice and A&E facilities, and to feel that they are behaving responsibly while still meeting their own needs.
Keywords. Walk-in centres, qualitative research, access to healthcare, help-seeking behaviours.
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Introduction |
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NHS Walk-in Centres were introduced as a means of providing more rapid and convenient access to healthcare for patients.1 They characteristically have long opening hours, are nurse-led and supported by clinical software, and offer the opportunity to consult a health professional (usually a nurse) without an appointment. An important aim of Walk-in Centres is reducing the load on GPs in primary care and accident and emergency (A&E) facilities.2
NHS Walk-in Centres have been subject to a range of evaluations, including investigations of the impact of the Centres on workload,3,4 quality of care provided,5 and satisfaction and reasons for use.6 However, little is known about how people use Walk-in Centres and in particular how they select Walk-in Centres from among the options available for their health problem, although the need for initiatives to be informed by patients' own views of services has been recognised.7 In particular there is a need to understand people's help-seeking behaviour in the context of multiple services (particularly those that are 'bolted on' to existing structures), and also there is a need to gain insight into what affects their choices, including perceptions of quality. We conducted a qualitative study of people's accounts of their use of an NHS Walk-in Centre.
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Methods |
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We obtained approval from the Leicestershire Research Ethics committee to conduct a study using semi-structured interviews with people who had recently attended the NHS Walk-in Centre located in Loughborough, a market town whose nearest A&E Department is located some 15 kilometres away in Leicester. The Loughborough NHS Walk-in Centre opened alongside a pre-existing Minor Injuries Unit in July 2000 and functioned as a combined unit.
Participants
People attending the Walk-in Centre/Minor Injuries Unit during a five week period were approached by the NHS staff and asked if they would be interested in being interviewed about their experiences and if they would agree to provide their contact details with a view to being contacted about the study. Of the 112 people approached, 45 (40%) agreed to provide contact details. These people were purposively sampled to represent a range of times of attendance and sex. Interviews were arranged with 23 (21%).
Interviews
Semi-structured interviews were conducted using a prompt guide (Box 1) based on literature review, issues that had been identified as being of interest to the NHS or of concern to health professionals and managers, and discussions within the research team. The guide covered the decision to seek help, choice of service, and patients' experiences of the service. It was used flexibly, in response to the ways in which participants wanted to direct the interview. All participants were interviewed at home by a multi-lingual researcher. All interviews were tape-recorded.
| BOX 1 Prompt guide Seeking help Prompt or trigger for the decision to seek help Perceived seriousness of the symptoms Perception of whether the problem would resolve without help Perception of what would be done to help the problem Whether the service was being used to sanction an approach to another service Role of lay referral system Choice of service Reasons why the patient selected the service she/he chose Roles of the various services available Whether symptoms were matched to perceptions of role of service Perceived quality of services, including
Influence of awareness of services Patients' experiences of the service they used Waiting times Communication with staff Confidence in quality of clinical care Physical environment of service Organisational issues Continuity of care Outcomes of care Overall satisfaction Future behaviour in relation to needing health care
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Analysis
Interviews were transcribed verbatim. Data analysis was based on the constant comparative method. Analysis began with open codes describing each unit of meaning within the transcripts, and included the use of 'in vivo' codes based on the terms used by participants themselves as well as more conceptual codes. Through careful comparison across transcripts, the open codes were developed and refined into organising themes or categories, which provided the coding frame for analysis using QSR N5 software.8 All authors were involved in developing the category specifications. The framework was continually checked, and modified where necessary to ensure an adequate fit with the data, and potentially disconfirming cases were explicitly considered. A reflexive audit trail of the development of the framework and its categories was maintained by CJ.
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Results |
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The 23 participants were aged 28–70 years. Ten participants were male, three were non-white, 17 had attended on a weekday and six at the weekend. All were resident within fifteen kilometres of Loughborough. Table 1 describes other characteristics of participants and shows the problems for which they were seeking help on this occasion. In their accounts, participants also referred to previous uses of the Walk-in Centre.
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Patterns of service use among patients, following the introduction of the new Walk-in-Centre were explored. The analysis generated three major themes: (1) seeking help (2) resources and (3) access.
Seeking help
More than half of the participants had used the Walk-in Centre before. Two types of help-seeking could be distinguished: execution/implementation, and professional advice.
Execution. This type of help-seeking described eight participants (see Table 1) who had decided or knew what was wrong with them and had a clear idea of the type of treatment they required. Their main purpose in help-seeking was to seek assistance in executing a plan of action on which they had already determined, either by themselves or on the advice of a health professional.
"... because he's had like these asthma attacks before then he's been on like the nebuliser at the doctors and I thought that's what he needed." (Participant 13)These patients chose the service that they believed would give them what they required. This usually meant choosing the service that was easily accessible and offered the shortest delay.
Professional advice. This second type of help-seeking described the motivations of fifteen participants who were uncertain about the nature of the problem, and particularly whether or not it was serious. They sought professional advice, along with treatment if necessary, and often wanted to resolve uncertainty about an anxiety-provoking situation.
"I had a problem with my mouth, there was a soreness in my mouth but it also meant that I couldn't open my jaw. Em and I had had it before but it ... it was a flare up and it was particularly bad that morning em so I wanted some advice about it ... when this sort of flared up again I wanted some advice there and then and I knew I couldn't get to see my doctor that morning because it wasn't an emergency. Em and I just wanted to speak to somebody really." (Participant 3)Most of these participants explained that their choice of service would be dependent on making some sort of assessment about the nature of the problem, for example the seriousness of the problem and whether healthcare could be delayed.
Accounts from participants suggested that the decision to seek help and the choice of service is often influenced by others, particularly when there is uncertainty about whether to seek help. The lay referral system9 affected not only whether to seek help, but also which service to use.
"And this friend told me that she had been to the NHS Walk-in Centre with a similar problem and she'd got em some help so I thought I'd give them a try." (Participant 4)
Resources and access
Participants' accounts suggested that they saw a menu of services being available, at least notionally, from which they could select: the Walk-in Centre, A&E Departments, NHS Direct, and GPs. The Walk-in Centre appears to function as a means of overcoming the barriers to healthcare associated with the other services. It was used by some to overcome the dilemma of having anxiety-provoking symptoms while wanting to be seen as appropriate users of healthcare service who did not bother their GP unnecessarily.
"Em. I only like to go to GPs when I feel there's a real problem. Em and I just wasn't sure about this, I went for advice and I felt they could give me the advice." (Participant 2)The GP was seen as a precious service with a limited number of appointments, and participants reported feeling hesitant about being seen to waste the GP's time. For many participants (13) their GP was seen as the ideal, a prized but scarce resource. Almost all (20) participants described difficulties in gaining access to their GP.
In some accounts, particularly from patients concerned with seeking professional advice rather than as a means of executing a plan, using the Walk-in Centre could seen as a compromise between their preferences for GP care and their need for rapid access.
"I was worried about this swelling, em and I ... she [receptionist at GP's] said there wasn't anything for that evening, em I went to the Walk-in Centre that's why because I was worried about it ... But if it was something that I ... I could let ... you know ... afford to wait, I would sooner see my own doctor." (Participant 23)Participants were very sensitive to the demands on the NHS and the need to protect NHS staff from unwarranted strain. There were frequent references to the pressures NHS staff experience and the need to allow people with more important needs to be dealt with. The inability of the service to deal with the demands on it was usually attributed to shortcomings of government policy rather than the failings of individual services or staff, suggesting a form of 'solidarity' with the NHS and other NHS users.
"Whenever I go to see the GP there is so many people in the waiting room waiting to see the guy or pop in, various people at the practice, that you do feel as though sometimes that em although you've got a five minute window or ten minute window, you do feel as though you know, alright he's said what he needs to say to me now I might as well get out because he's got a lot of people to see." (Participant 11)Using the Walk-in Centre meant avoiding the stigma and anxiety of being seen to "waste" the GP's time or take resources from someone more "deserving"."I don't it's the doctors at all, I think it's the support or ... I think it's ... it's basically political, I think it's the government cutting ... they cut back on so many services I think and too much pressure on nurses, doctors, health service side." (Participant 20)
"Well yes. If ... if you think you're taking the place of someone that's really, really ill like a child that's throwing up and being really poorly, you know, it's not fair, if you can wait a bit longer." (Participant 21)People using the Walk-in Centre reported as a benefit that they were not required to decide whether or not their problem amounted to an emergency needing an urgent appointment, were not required to negotiate access with receptionist, and were not required to fit in with limited appointment slots.
"I would rather use the Walk-in Centre than the doctors ... Yeah em, yeah, I really would because I find the doctors a pain in the arse, I can't get past the receptionist at the doctors. Em I don't use it, in fact I don't use the doctors very often but every time I go I always get the feeling I'm wasting my time. And yet I didn't get that at all there, no, you know." (Participant 18)The healthcare professionals at the Walk-in Centre were reported as pleasant with good communication skills and time to listen, making patients feel valued, rather than a nuisance.
The Walk-in Centre was also seen as offering considerable practical advantages, avoiding the perceived difficulties with lengthy waits and difficulties of travel associated with attending an A&E department. It was viewed by some as a method of negotiating the system, for example, in validating the need for GP care or overcoming lengthy waits expected at A&E.
"Yes, I think I would because what she got me ... she ... I still got my appointment at the doctors in the end and I felt it was more justified because the [Walk-In] nurse had said [to see him] first." (Participant 5)
Knowledge of the Walk-in Centre
Participants came to know about and use the Walk-in Centre by a variety of routes. The majority (14) were aware of the Centre because they had attended before either for themselves or with family members. Recommendations from family members, friends or colleagues were frequently reported (13). These suggestions tended to come from people with some medical knowledge (6) or positive experiences of the service (8). Referrals from GPs, hospital and GP's receptionists were a feature of some (7) accounts.
"... I'd heard good reports from a number of people about the drop-in Centre, I thought as a first port of call I would go there rather than go, waste time at A&E all night." (Participant 11)There was some uncertainty concerning the purpose of the Walk-in Centre and its role within the healthcare system.
"I am still not very clear what the Walk-in Centre is there for. Em perhaps that's my fault for not finding out more but em I don't ... it's something I've never come across before." (Participant 17)Participants (8) were also unsure about which services were available within the Centre. It was not always clear to participants (10), even those who had used the service before, whether or not a doctor would be available at the Centre.
"there was a gentleman that was to-ing and fro-ing and I would have thought that he was doctor. He looked like, you know, he was wearing a stethoscope but maybe I'm wrong I don't know." (Participant 8)Views on whether a doctor was necessary in order to receive appropriate care were mixed. In some cases participants (14) felt that appropriate care was, or could be dependent on a doctor being present, with more than half of the participants suggesting that the service could be improved by the continuous presence of a doctor. Some felt that nursing care was sufficient (12), at least for the problem that they had attended for, while some accounts suggested that the roles of nurses and doctors were interchangeable.
"As far as I'm concerned they were all ... they should all know what they're doing, they are all qualified so ... it's just fine ... it's fine by me. As long as I've got an opinion on it and something was done, that was the main thing." (Participant 20)
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Discussion |
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Our study suggests that users of a Walk-in Centre use it as an important complement to the range of other services available to them. People use the service for a variety of purposes: some use it as a substitute for a preferred service which is less accessible; others use it in preference to other services because it allows them to execute actions more easily and conveniently. Importantly, the Walk-in Centre functions as a way for people to use the NHS without feeling that they are increasing the burden of what were perceived to be over-stretched general practice and A&E facilities, and to feel that they are behaving responsibly while still meeting their own needs. The Walk-in Centre represents a valued addition to the menu of options available to people confronted with a health problem.
This study has a number of limitations. The views described here may be specific to the Loughborough setting, and it is possible that other patterns of service use and preference could be found in patients choosing other services. The views of non-users of the service were not obtained.
This study does, however, offer important insights into how people might use an NHS Walk-in Centre. It suggests that people using NHS Walk-in centres may be distinctive compared with users of such services in other countries. A review of the international literature indicates that Walk-in users in other countries choose this form of care mainly for reasons of convenience and tend to be very satisfied.2 Convenience was certainly one factor in the choices made by people in our study. Lengthy waits were disliked not only because of the practical problems, but also because the potential for anxiety was increased. Access to the Walk-in Centre was seen as offering considerable advantages in waiting times.
It is clear, however, the convenience is only part of the story for NHS users in our setting. Our study suggests that people's motivations for choosing and using the NHS Walk-in Centre were much more complex, and influenced by people's social positioning in relation to a publicly funded health service with universal access. It is clear that many participants in our study were highly sensitised to the problems of heavy demand on general practice resources. Their accounts acknowledged the moral character of help-seeking,10 in which their responsibilities to use services in a public-spirited way had to be balanced with their own needs and anxieties. An important barrier to obtaining healthcare through the established services was the need to be seen as an appropriate user. A&E services were seen as favouring patients with serious life threatening problems, while GPs were seen as a valued but scarce resource with unclear rules determining who has legitimate access. Using A&E or general practice opened up the possibility of an identity threat,11 in which participants risked being deemed by receptionists or health professionals as being selfish or neurotic time-wasters. The Walk-in Centre, open to all without having to justify their attendance to a receptionist, insist that the problem was urgent, or feel that the place of others was being taken, offered a very welcome means of resolving these dilemmas. By opening up an alternative means of seeking a professional opinion without disturbing the patient's relationship with his or her GP or being made to feel guilty,12 Walk-in Centres may create entirely new patterns of service use.
These findings raise important questions about what happens when additional "bolt-on" services are added to the menu of health services available to people. People in systems such as the NHS may respond to these new services in ways that reflect their solidarity with the NHS and other NHS users, and their willingness to put up with a less than optimal service in recognition of its public character. For example, people may use an NHS Walk-in Centre even though they would much prefer to see their GP, and, moreover, they may express much gratitude for the availability of the Centre even though it is not exactly what they want. This 'gratitude factor' that has been identified in previous studies, which have found, for example, that patients are grateful for the care provided by nurses and tend to make allowances for shortcomings by attributing these to lack of resources or the system.13 In addition, there may be reluctance on the part of users of a service to criticise it for fear of losing it. These kinds of issues pose problems for evaluation, particularly when the users of services may be unaware of the implications of different types of services for coordination and integration of care.
In conclusion, NHS Walk-in Centres do appear to improve access to healthcare in important ways. In particular they are helpful to people concerned about using traditional services because of uncertainty about the severity of the problem or the practical problems associated with use of those services. These findings imply that attention needs to be given to the ways in which people choose and use services when confronted with choices, and about the consequences of those choices.
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Declaration |
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Funding: the study was funded by Leicestershire and Rutland NHS Trust.
Ethical approval: granted by Leicestershire Research Ethics Committee.
Conflicts of interest: none.
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Acknowledgments |
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We would like to thank Leicestershire and Rutland NHS Trust for funding for this study, the participants in the study, the staff at Loughborough Walk-in Centre for facilitating the study, and Sheila Gokhani, who carried out the interviews. Jennifer Kurinczuk is funded by a National Public Health Career Scientists Award from the Department of Health and NHS R&D (PHCS 022).
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References |
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1 Salisbury C, Chalder M, Manku-Scott T, Pope C, Moore L. What is the role of Walk-in Centres in the NHS? Br Med J 2002; 324: 399–402.
2 Salisbury C, Munro J. Walk-in centres in primary care: a review of the international literature. Br J Gen Pract 2003; 53: 53–59.[Web of Science][Medline]
3 Hsu RT, Lambert PC, Dixon-Woods M, Kurinczuk JJ. Effect of NHS Walk-in Centre on local primary healthcare services: before and after observational study. Br Med J 2003; 326: 530.
4 Chalder M, Sharp D, Moore L, Salisbury C. Impact of NHS Walk-in Centres on the workload of other local healthcare providers: time series analysis. Br Med J 2003; 326: 532.
5 Grant C, Nicholas R, Moore L, Salisbury C. An observational study comparing quality of care in Walk-in Centres with general practice and NHS Direct using standardised patients. Br Med J 2002; 324: 1556.
6 Salisbury C, Manku-Scott T, Moore L, Chalder M, Sharp D. Questionnaire survey of users of NHS Walk-in Centres: observational study. Br J Gen Pract 2002; 52: 554–560.[Web of Science][Medline]
7 Gulliford M, Hughes D, Figeroa-Munoz J, Hudson M, Connell P, Morgan M, Beech R, Gibson B, Arumugam C, Mohiddin A, Sedgwick J. Access to health care—a scoping exercise. London: NHS SDO.
8 Gahan C, Hannibal M. Doing qualitative research using QSR NUD*IST. London: Sage; 1998.
9 Friedson E. Client control and medical practice. Am J Soc 1959; 65: 374–382.[CrossRef]
10 Jeffery R. Normal rubbish: deviant patients in casualty departments. Soc Health Illness 1979; 1: 90–107.
11 Coyle, J. Exploring the meaning of dissatisfaction with health care: the importance of 'personal identity threat'. Soc Health Illness 1999; 21: 95–124.
12 Rogers A, Hassell K, Nicolaas G. Demanding patients? Analysing primary care use. Buckingham: Open University Press; 1999.
13 Altschul AT. The consumer's voice: nursing implications. J Advanced Nursing 1983; 8: 175–183.[Web of Science][Medline]
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